Provider Demographics
NPI:1629120415
Name:MUNISING MEMORIAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:MUNISING MEMORIAL HOSPITAL ASSOCIATION
Other - Org Name:BAY CARE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAUTIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-387-4110
Mailing Address - Street 1:1500 SAND POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:MUNISING
Mailing Address - State:MI
Mailing Address - Zip Code:49862-1406
Mailing Address - Country:US
Mailing Address - Phone:906-387-4338
Mailing Address - Fax:906-387-2825
Practice Address - Street 1:1500 SAND POINT ROAD
Practice Address - Street 2:
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862-1406
Practice Address - Country:US
Practice Address - Phone:906-387-4338
Practice Address - Fax:906-387-2825
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNISING MEMORIAL HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-18
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363AM0700X
MI1060000115261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Z21000OtherBLUE SHIELD
MI23-8650OtherRHC CERTIFICATION NUMBER (CMS)
MI23-8650OtherRHC CERTIFICATION NUMBER (CMS)
0M40920Medicare PIN